Raising Expectations

Created on 15th May 2009

Barry Jones, one of London's top consultant and reconstructive plastic surgeons, describes what to expect with the endoscopic browlift, and the keyhole surgery that has revolutionised this precise facial surgery

Endoscopes, or surgical telescopes, have revolutionised many aspects of surgery in recent years enabling operations to be carried out via small, hidden incisions leaving no visible scars - ‘keyhole surgery'. The browlift was the first facial cosmetic procedure to benefit from this technology allowing rejuvenation of the upper third of the face through small scars (1-1.5cm in length) all hidden within the hair rather than a long Alice band style incision. 

With the passage of time, the forehead frequently sags causing the eyebrows to move downward, particularly in their outer part, and both transverse and vertical frown furrows to become more apparent.

This combination tends to make the eyes look smaller and the individual appear tired, cross or angry when they are not. The endobrow (endoscopic browlift) is designed to elevate the outer part of the eyebrows and to weaken the muscles which cause frowning. An approximate idea of what can be achieved can be gained by placing the palms of the hands at the outer edges of the eyes, above the eyebrows, and drawing the skin gently upwards and outwards to raise both the brow and forehead area. The elevation should not be vertical since this creates a look of surprise.

Endobrow may be performed as an isolated procedure or in combination with other facial or eyelid surgery. It is also useful for correcting natural asymmetries of the eyebrows by raising only one, or one more than the other and to treat a drooping brow associated with facial palsy (Bell's palsy).

The operation is carried out under light general anaesthesia. It is possible to use a sedation technique but difficult to provide complete patient comfort. Admission to hospital is on the day of surgery and, although the operation takes only 40 minutes or so to complete, I prefer patients to remain and relax for 24 hours.

Generally there are five small incisions, three just behind the frontal hairline and one at each temple. The forehead skin is separated from the deeper tissues using specially designed instruments. The endoscope is a surgical telescope attached to a television camera which provides the surgeon with excellent vision and magnification. This allows the muscles which cause furrowing of the brow to be weakened without injuring important adjacent structures, such as nerves and blood vessels, and then for the outer part of the eyebrows to be elevated.

Research suggests that the brows need to be supported for 8-12 weeks to achieve the maximum and most long-lasting effect and there are a variety of ways of achieving this. My preference is to use sutures which dissolve over a period of three to six months.

They are more convenient and reliable than alternatives such as tissue glue, screws and staples and do not cause alopecia. No skin is removed during the course of the operation, any excess is redistributed towards the back of the head and its elasticity will cause it to retract naturally. Unlike open brow surgery this technique avoids elevating the frontal hairline.

No specific preparation is necessary although it is important to avoid any medication which will cause bleeding or excessive bruising, such as Aspirin, Vitamin E and non-steroidal anti-inflammatory drugs. Hair tinting can be continued up to the time of surgery but strong, bleached-based colourants should be avoided for 4-6 weeks afterwards: vegetable-based hair dyes are perfectly acceptable however.

I use little in the way of dressings after the operation - paper tape supporting the bridge of the nose helps to reduce swelling.There may be some swelling of the brow and puffiness or bruising around the eyelids which tends to resolve over ten days or so. 

While pain is not a feature of facial surgery in general, headaches are commonly associated with brow lift. Often these will resolve during the first few hours but they can persist for a day or two. Generally they will respond to pain-relieving medication. There may be some numbness at the top of the scalp, behind the incisions, which is often replaced by feelings of ‘pins and needles' or itching as full sensitivity recovers over a period of weeks. All the stitches dissolve spontaneously but I like to check patients at a week or so to be sure that all is progressing satisfactorily. 

Complications after endobrow are uncommon but, as with all types of surgery, not unknown. Haematoma, a collection of blood beneath the skin like an excessive bruise, can complicate any operation, the risk in the brow is 0.1 per cent, and it may require a small operation to remove accumulated fluid. The risk of infection is extremely small, 0.1 per cent, though routine antibiotic prophylaxis is provided.

The upper branch of the facial nerve, which works the muscle that raises the eyebrows, travels close to the field of surgery but is well protected and should not be injured. Such injuries, though exceptionally rare, are most likely to be a result of bruising and may be expected to recover over a period of 8-12 weeks. The scars behind the frontal hairline may be detectable if the hair is swept back when they are new but are well concealed once mature.

In summary, the endobrow creates a smoother forehead, slightly higher eyebrows at their outermost extent and minimises frown lines. This will provide a fresher, more relaxed and youthful appearance to the upper face and eyes while avoiding an unnatural, operated or startled look. It may be carried out either alone or in combination with other facial procedures and in some individuals will be more appropriate to treat apparently heavy upper eyelids than eyelid surgery itself. It does require specific training on the part of the surgeon and specialised equipment and so is not available in all hospitals.
CS&AM